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Zinc as adjunct treatment in infants aged between 7 and
120 days with probable serious bacterial infection:
a randomised, double-blind, placebo-controlled trial
Shinjini Bhatnagar, Nitya Wadhwa, Satinder Aneja, Rakesh Lodha, Sushil Kumar Kabra, Uma Chandra Mouli Natchu, Halvor Sommerfelt,
Ashok Kumar Dutta, Jagdish Chandra, Bimbadhar Rath, Mamta Sharma, Vinod Kumar Sharma, Mohini Kumari, Tor A Strand
Lancet 2012; 379: 2072–78
Published Online
May 31, 2012
DOI:10.1016/S0140-
6736(12)60477-2
See Comment page 2031
Centre for Diarrhoeal Diseases
and Nutrition Research
(Prof S Bhatnagar PhD,
N Wadhwa MD), Department of
Paediatrics (R Lodha MD,
Prof S K Kabra MD), All India
Institute of Medical Sciences,
New Delhi, India; Paediatric
Biology Centre, Translational
Health Science and Technology
Institute, Gurgaon, Haryana,
India (Prof S Bhatnagar,
N Wadhwa, U C M Natchu MD);
Department of Paediatrics,
Lady Hardinge Medical College
and Kalawati Saran Children’s
Hospital, New Delhi, India
(Prof S Aneja MD,
Prof A K Dutta MD,
Prof J Chandra MD,
Prof B Rath MD); Department of
Nutrition, Harvard School of
Public Health, Boston, MA, USA
(U C M Natchu); Centre for
International Health,
University of Bergen, Bergen,
Norway (Prof H Sommerfelt PhD,
T A Strand PhD); Division of
Infectious Disease Control,
Norwegian Institute of Public
Health, Oslo, Norway
(Prof H Sommerfelt, T A Strand);
Department of Paediatrics,
Deen Dayal Upadhyay Hospital,
Hari Nagar, New Delhi, India
(M Sharma MD, V K Sharma MD,
M Kumari MD); and Medical
Microbiology, Department of
Laboratory Medicine, Innlandet
Hospital Trust, Lillehammer,
Norway (T A Strand)
Correspondence to:
Prof Shinjini Bhatnagar,
Paediatric Biology Centre,
Translational Health Science and
Technology Institute, Gurgaon,
Haryana 122016, India
shinjini.bhatnagar@thsti.res.in
Summary
Background Serious bacterial infections are a major cause of death in early infancy in developing countries.
Inexpensive and accessible interventions that can add to the effect of standard antibiotic treatment could reduce
infant mortality. We measured the effect of zinc as an adjunct to antibiotics in infants with probable serious
bacterial infection.
Methods In this randomised, double-blind, placebo-controlled trial, we enrolled infants aged 7–120 days with probable
serious bacterial infection at three hospitals in New Delhi, India, between July 6, 2005, and Dec 3, 2008. With
computer-generated sequences, we randomly assigned infants in permuted blocks of six, stratified by whether
patients were underweight or had diarrhoea at enrolment, to receive either 10 mg of zinc or placebo orally every day
in addition to standard antibiotic treatment. The primary outcome was treatment failure, which was defined as a need
to change antibiotics within 7 days of randomisation, or a need for intensive care, or death at any time within 21 days.
Participants and investigators were masked to treatment allocation. All analyses were done by intention-to-treat. This
trial is registered with ClinicalTrials.gov, number NCT00347386.
Findings 352 infants were randomly assigned to receive zinc and 348 to placebo. 332 given zinc and 323 given placebo
could be assessed for treatment failure. Significantly fewer treatment failures occurred in the zinc group (34 [10%])
than in the placebo group (55 [17%]; relative risk reduction 40%, 95% CI 10–60, p=0·0113; absolute risk reduction
6·8%, 1·5–12·0, p=0·0111). Treatment of 15 (95% CI eight to 67) infants with zinc would prevent one treatment
failure. Ten infants receiving zinc died compared with 17 given placebo (relative risk 0·57, 0·27–1·23, p=0·15).
Interpretation Zinc could be given as adjunct treatment to reduce the risk of treatment failure in infants aged
7–120 days with probable serious bacterial infection.
Funding Department of Biotechnology, Government of India; the European Commission; the Meltzer Foundation; and
the Research Council of Norway.
Introduction
Of the 7·8 million deaths a year in children younger than
5 years in Africa, southeast Asia, and the eastern
Mediterranean, more than 3 million are in neonates. 1
Sepsis and pneumonia—responsible for 25% of these
deaths 1 —are often clinically difficult to distinguish in
young infants. Of the 1 million neonatal deaths that
occur annually in India, more than a quarter are
attributed to serious bacterial infections, such as pneumonia,
sepsis, and meningitis. 2 Many young in fants in
hospital have been admitted because of these severe
infections. 3 Despite advances in antimicrobial treatment,
outcomes remain poor. 4 Development of inexpensive and
accessible interventions that could improve treatment
outcomes and reduce case fatality is important.
Several animal and human studies 5–7 have shown that
zinc is crucial for immune function. Zinc given orally
during an episode of childhood diarrhoea reduces
duration and severity of illness. 8–11 In a communitybased
trial of infants and children with diarrhoea in
North India, 12 zinc supplements reduced diarrhoeal
morbidity, raised the number of circulating T cells
(especially CD4 cells), and improved the cutaneous
delayed hypersensitivity reaction.
A reduced risk of treatment failure will shorten time in
hospital, lower use of high-generation antimicrobials and
treatment cost, and possibly reduce mortality. We aimed
to estimate the efficacy of 10 mg of oral zinc daily
combined with standard antibiotic treatment in infants
aged between 7 and 120 days with probable serious
bacterial infection.
Methods
Study design and participants
We undertook a randomised, double-blind, placebocontrolled
trial from July 6, 2005, to Dec 3, 2008, at three
tertiary hospitals in New Delhi, India (Kalawati Saran
Children’s Hospital, Deen Dayal Upadhyay Hospital, and
All India Institute of Medical Sciences). We screened
infants aged 7–120 days in emergency depart ments for any
of the following clinical symptoms or signs of possible
serious bacterial infection: convulsions, fast breathing,
2072 www.thelancet.com Vol 379 June 2, 2012

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severe chest indrawing, grunting, bulging fontanelle,
axillary temperature 37·5°C or higher or lower than
35·5°C, refusal to feed or drink, uncon sciousness or
lethargy, no attachment to or suckling at breast (in
breastfed infants), excessive crying or irritability, diarrhoea,
or cyanosis (appendix). These criteria were adapted from
the definitions used by the Integrated Management of
Neonatal and Childhood Illnesses strategy. 13
We included preterm infants (≤32 weeks of gestation)
only when they were older than 2 months at screening.
We excluded infants who weighed 1500 g or less; needed
mechanical ventilation, inotropic drugs, or exchange
transfusion; had major congenital anomalies, inborn
errors of metabolism, severe birth asphyxia, renal failure,
surgical or other disorders interfering with oral feeding,
pre-existing seizure disorders, or any other serious
underlying medical problems; were born to HIV-infected
mothers; or had received zinc during the present episode
of infection.
We measured serum C-reactive protein concentration
with a semi-quantitative latex agglutination assay
(Plasmatec Laboratory Products, Bridport, Dorset, UK)
immediately after eligibility was established. Infants with
a concentration of 12 mg/L or higher were judged to have
probable serious bacterial infection and were eligible for
the trial. Study physicians were present 24 h a day and
obtained written informed consent from the guardians
of these patients (or with a thumbprint from those who
were illiterate) in the presence of a witness. Patients were
then randomly assigned to receive zinc or placebo.
Infants who could not be fed orally were observed for up
to 24 h of stabilisation and randomly assigned only when
they were able to tolerate oral feeding. The ethics committees
of all hospitals and WHO’s Ethics Review
Committee approved the study protocol.
Randomisation and masking
We stratified patients by whether they were underweight
(ie, weight-for-age Z scores 14

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12 502 infants screened
10 186 infants with signs of PSBI
6936 infants with signs of PSBI and no exclusion criteria
980 eligible for enrolment
5956 infants with concentration of
C-reactive protein

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from baseline to recovery between the two groups with
the Student’s t test. The effect of zinc on laboratory
markers of inflammation (C-reactive protein and procalcitonin)
at 72 h and at recovery was compared with
the Mann-Whitney test.
We did predefined subgroup analyses to assess
whether diarrhoea or infants being underweight at
enrolment modified the effect of zinc. Interactions
were assessed with interaction terms in generalised
linear models of the binomial family with log links
to estimate RRs and identity links for RDs. We also did
a post-hoc analysis restricted to infants aged 7 to
60 days.
This trial is registered with ClinicalTrials.gov, number
NCT00347386.
Role of the funding source
The sponsors of the study had no role in study design,
data collection, data analysis, data interpretation, or
writing of the report. SB, NW, TAS, RL, UCMN, and HS
had full access to all the data in the study and had final
responsibility for the decision to submit for publication.
Results
Figure 1 shows the trial profile. Table 1 shows baseline
charac teristics. 148 (42%) of 352 in the zinc group versus
137 (39%) of 348 given placebo received ampicillin and an
amino glycoside; 163 (46%) versus 163 (47%) received a
third-generation cephalosporin and an aminoglycoside;
and 41 (12%) versus 48 (14%) were given intravenous
cloxacillin.
Concentrations of C-reactive protein and procalcitonin
at baseline were high in both groups (table 1). Median
concentration of C-reactive protein was lower in infants
with diarrhoea (28·7 mg/L, IQR 15·2–53·8) than in those
without diarrhoea (37·3 mg/L, 20·2–64·2). 44% of all
patients (302 of 681) had serum zinc concentrations of
less than 9·2 μmol/L at baseline. Median serum zinc
concentrations were 10·2 μmol/L (IQR 8·1–12·9) in
children with diarrhoea compared with 9·3 μmol/L
(7·4–11·7) in those without diarrhoea. No protocol deviations
were recorded in either group.
Treatment failure could be assessed in 655 infants
(figure 1). Four patients (one given zinc; three placebo)
who had treatment failure left the study before recovery
could be recorded. Treatment efficacy—ie, reduction in
relative risk of treatment failure—was 40% (95% CI
10–60; p=0·0113; table 2). The absolute risk reduction
was 6·8% (1·5–12·0; p=0·0111); therefore, 15 (eight to 67)
infants with probable serious bacterial infection would
need to be treated with zinc in addition to antibiotics to
prevent one treatment failure. A similar efficacy (54%,
20–74; p=0·0045) was noted when analysis was restricted
to infants aged between 7 and 60 days.
Cause of treatment failure was assigned by worst
outcome and first cause (table 2). Of 89 infants who
had treatment failure, 76 had their antibiotics changed
Zinc (n=352)
within 7 days (table 2). Although we classed death as a
treatment failure at any time up to day 21, seven of eight
who died after 7 days of treatment had a change of
antibiotics in the first week and therefore fulfilled
criteria for treat ment failure even before they died.
Nearly two-thirds of decisions to change antibiotics
(17 of 29 in zinc group; 33 of 47 in placebo group)
occurred within 96 h of randomisation. 15 (5%) of the
332 infants given zinc and 17 (5%) of the 323 given
placebo needed a second change in antibiotics within
the 21 days.
The efficacy of zinc was higher in infants with diarrhoea
at enrolment than in those without diarrhoea (p=0·0260;
figure 2). Three children (one in the zinc group; two
in the placebo group) needed a change of antibiotics
Placebo (n=348)
Age (days) 54·9 (31·1) 54·0 (28·7)
>7–30 96 (27%) 86 (25%)
31–60 108 (31%) 123 (35%)
61–120 148 (42%) 139 (40%)
Female sex 124 (35%) 121 (35%)
Weight of naked infant (kg) 3·36 (1·02) 3·41 (1·10)
Weight-for-age Z score

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Zinc (n=332)* Placebo (n=323)* Relative risk (95% CI) Risk difference (95% CI)
Treatment failure (by worst outcome) 34 (10%) 55 (17%) 0·60 (0·40 to 0·90) 0·07 (0·02 to 0·12)
Death 10 (3%) 17 (5%) 0·57 (0·27 to 1·23) 0·02 (–0·01 to 0·05)
Need for intensive care 1 (

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Zinc
(n=332)
Placebo
(n=323)
Lethargy or unconsciousness 11 (3%) 19 (6%)
Fever or hypothermia 8 (2%) 13 (4%)
No attachment to or suckling at breast (in
8 (2%) 15 (5%)
breastfed infants) or acute refusal to feed or drink
Convulsions 3 (1%) 8 (2%)
Bulging fontanelle 1 (

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private health-care systems for treatment of acute
diarrhoea in many countries of low and middle income
and the incremental costs to make this intervention
available for young infants with probable serious bacterial
infection would be small.
Contributors
SB formulated the research question and designed the study. SB, HS,
and TAS wrote research grants. SB, NW, SA, RL, SKK, UCMN, AKD, JC,
BR, MS, VKS, MK, and TAS developed the standard operating
procedures. SB, NW, RL, SKK, AKD, JC, BR, MS, VKS, and MK
implemented the trial. SB, NW, SA, and TAS supervised clinical and data
management. SB, NW, SA, RL, UCMN, HS, and TAS analysed data.
SB, NW, RL, UCMN, HS, and TAS interpreted the findings. SB, NW, SA,
RL, SKK, UCMN, HS, and TAS wrote the report.
Conflicts of interest
We declare that we have no conflicts of interest.
Acknowledgments
The study was funded by the Department of Biotechnology, Ministry of
Science and Technology, Government of India (BT/PR5238/MED/14/
610/2004). We also received funding from the European Commission
(EU-INCO-DC contract number INCO-FP6-003740), the Meltzer
Foundation (Bergen, Norway), and the Research Council of Norway (project
number 172226). We thank the medical and nursing staff of the three
hospitals for their contribution; the patients and their parents;
Ritu Chawla, Uday Pal Singh Kainth, Anil Gulati, Arvind Bagga, and
Madhulika Kabra for providing clinical support to patients enrolled in
the study at the Deen Dayal Upadhyay Hospital and All India Institute of
Medical Sciences; Arti Kapil for supervising the blood cultures;
Anil Kumar Sharma for assisting in quality assurance and supervision of
the research staff; Savita Saini for undertaking the micronutrient assays
and providing technical support for all other laboratory work;
Mukesh Juyal for secretarial support; Dharmendra Sharma for data
management support and analysis of data; and Olivier Fontaine (WHO)
for providing the intervention (zinc and placebo tablets from Nutriset)
and periodic reviews of study procedures.
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